Penelope Ward
Lithonia
Summary
Dynamic Workers Compensation Adjuster with proven expertise at Sedgwick Claims Management in claims processing and negotiation. Skilled in reserve calculations and vendor coordination, I excel in achieving favorable outcomes through strategic planning and effective communication. Committed to delivering timely resolutions while maintaining strong professional relationships.
Overview
6
6
years of professional experience
Work History
Workers Compensation Adjuster
Sedgwick Claims Management
11.2022 - Current
- Analyzes and processes complex or technically difficult workers' compensation claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution
- Negotiates settlement of claims within designated authority.
- Calculated and assigned timely reserves to claims; managed reserve adequacy throughout claim lifecycle.
- Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles claims within designated authority level.
- Managed litigation process to ensure timely and effective claims resolution.
- Coordinated vendor referrals for additional investigation and litigation management.
- Utilized cost containment techniques and strategic vendor partnerships to optimize claim costs.
- Communicates claim activity and processing with the claimant and the client; maintains professional client relationships.
- Ensures claim files are properly documented and claims coding is correct.
Workers Compensation
Berkshire Hathaway GUARD Insurance Companies
Wilkes-Barre
02.2022 - 11.2022
- Advised employers on the proper management and impact of Workers’ Compensation claims.
- Made effective decisions on compensability determinations and benefit authorizations by utilizing resources such as medical management, SIU, subrogation, recovery, and legal, ensuring accurate determinations and favorable outcomes.
- Calculates and pays benefits in accordance with the law. Ensures that the claim is managed in accordance with all legal requirements including the issuance of appropriate notices and filings.
- Liaised among employer, medical provider, and injured worker to facilitate communication and resolution of claims.
- Assisted injured workers in achieving full medical recovery and safe return to work through timely medical treatment and support.
- Manages claims with an outcome-based and resolution focus. Demonstrates highly effective strategic plans for future handling that are well outlined in plans of action and followed through in a timely fashion.
- Prepares and maintains timely, accurate reserves on all claims for expected future costs of medical treatment, benefits and other elements in accordance with Claims Handling Guidelines.
- Managed vendors and providers, identifying needs for assignment and removal, effectively utilizing vendor expertise while maintaining ownership of claims.
Claims Analyst, Subrogation
EXL Service
Hartford
11.2021 - 01.2022
- Reviewed claim files to identify subrogation opportunities, facilitating recovery efforts.
- Maximized the subrogation recovery and reached a settlement agreement by evaluating facts, evidence, liability, damage, and other factors before insurance company negotiations.
- Developed and pursued strategies for recovery of claims, enhancing overall recovery rates.
- Analyzed claims liability issues to determine evidence to pursue recovery from 3rd parties.
- Submitted liability or damage analysis files to arbitration to prevail against the adverse party.
- Referred cases and organized documents for outside collection agencies and attorneys, streamlining the recovery process.
Contract Agent for Various Clients
TTEC Company
08.2020 - 11.2021
- Advised clients on retiree health exchange options, ensuring understanding of benefits and compliance with regulations.
- Managed claims processing and customer service inquiries, facilitating timely resolutions and enhancing client satisfaction.
- Investigated health cases to identify eligibility and ensure compliance with health regulations, contributing to accurate case outcomes.
- Assisted clients with healthcare coverage options by providing expert advice and guidance.
Education
Associate of Applied Science - Social Work
University of Guyana
Turkeyen, Guyana01-2005
Skills
- Claim analysis
- Claims negotiation
- Settlement negotiation
- Reserve management
- Reserve calculations
- Vendor analytics
- Investigative skills
Technologies And Licenses
PBM software, Property and Casualty License, Health Insurance License, Workers Compensation Adjuster License-Texas, Workers Compensation Adjuster License-Florida, PA, NJ, IL, OH, FL, GA
Timeline
Workers Compensation Adjuster
Sedgwick Claims Management
11.2022 - Current
Workers Compensation
Berkshire Hathaway GUARD Insurance Companies
02.2022 - 11.2022
Claims Analyst, Subrogation
EXL Service
11.2021 - 01.2022
Contract Agent for Various Clients
TTEC Company
08.2020 - 11.2021
Associate of Applied Science - Social Work
University of Guyana